Strategies for Reducing the Heavy Tolls of Drug Misuse

Announcer:
You’re listening to Clinician’s Roundtable on ReachMD, and this episode is sponsored by Quest Diagnostics. Here’s your host, Dr. Jennifer Caudle.

Dr. Caudle: 
Welcome to Clinicians Roundtable on ReachMD. I'm your host, Dr. Jennifer Caudle. And joining me to discuss how we can use medication monitoring to reduce the heavy tolls of drug misuse is Dr. Steven Stanos, who's the Executive Medical Director of Rehabilitation and Performative Medicine as part of the Swedish Pain Services at the Swedish health system in Seattle, Washington. Dr. Stanos, thanks so much for being here today.

Dr. Stanos:
Thanks for having me.

Dr. Caudle:
Let's start with some background, Dr. Stanos. What kind of data does drug monitoring provide? And how do we use it to guide clinical decision making?

Dr. Stanos: 
Well, I think drug monitoring for pain management is primarily urine drug monitoring. And I like to use the term drug monitoring versus toxicology or testing. But with urine drug monitoring, while what we're looking to do is to either get presumptive or definitive testing. So, we can get testing that can be evaluated right in the clinic which is usually done by immunoassays, which aren't as sensitive and specific. Or we can get more definitive testing, which is usually a send-out that uses gas or liquid chromatography which can actually give you a lot more higher sensitivity and specificity.

So, we have two different types, the kind of short-term information about the use of medicines or substances a patient may be using or longer term getting more definitive breakdown of the medications many times especially with pain medicines where we can actually find specific metabolites. So the different types are the immunoassays, which are for more short term or point of care testing. And then the more definitive testing which includes confirmation testing, which is sent out, usually takes three to four days but gives you more information specifically about the metabolites. And it can help kind of clarify if there's any discrepancies with the immunoassay testing.

Dr. Caudle:
And with that in mind, what are some of the consequences of inadequate drug monitoring? 

Dr. Stanos: 
Well, for inadequate drug monitoring, or urine monitoring, specifically, within a pain management environment inadequate testing could lead to the wrong clinical decision. You may miss that a patient may be struggling with opioid use disorder, or another substance use disorder and you didn't do the testing correctly or didn't do the testing at all. So, I think obviously, the first thing would be missing a really critical point in a patient's kind of story that you could really help with that patient and prevent harm. Many times, an abnormal urine screen may be the first sign that a patient is struggling with a substance use disorder or opioid use disorder.

Second would be I think inadequate testing would be not interpreting the test correctly. So, we normally have two different types of tests. We have the immunoassays, which are the point of care tests and then we have send-out tests. So, you could unfortunately maybe base a clinical decision on a point of care test that may be a false positive or a false negative and that may lead to obviously problems with your patient and patient care.

The third part would be not doing adequate testing in many cases can impact that therapeutic relationship you have with your patient. And many studies have shown doing urine monitoring and creating an environment where patients are closely being monitored, is really going to ensure less problems that patients develop over time. So inadequate testing can lead to missing an important clinical situation the patient presents with, it could also mean making the wrong clinical decision by not interpreting the results correctly.

Recently, the CDC has put together draft guidelines, which are going to be an update to the 2016 CDC guideline for prescribing opioids for chronic pain. Within the guideline draft there is some specific mention about when to use urine monitoring. And this has been somewhat of a controversy because it varies from state to state, and different groups have different recommendations around when to do testing. So at least what the draft recommendations that are hopefully going to be finalized by the end of 2022 the CDC says that you should be doing urine monitoring during subacute chronic pain management and consider testing, they use the term toxicology which, I think is a little punitive versus monitoring. But they say that you should be doing testing for prescribed medications and for other nonprescribed medications, because I think the CDC recognizes that it's really important for clinicians to be aware that we really need to be looking at not just the say the opioid medicines patients are taking, but to also be checking for benzodiazepines, cannabis, other substances they may be using that potentially could cause harm as well.

Dr. Caudle:
For those of you who are just tuning in, you're listening to Clinicians Roundtable on ReachMD. I'm your host, Dr. Jennifer Caudle, and I'm speaking with Dr. Steven Stanos about the heavy tolls of drug misuse.

So, Dr. Stanos, let's turn our attention to drug monitoring. What key elements do we need to monitor our patients effectively?

Dr. Stanos:
So, the key elements for monitoring, I think you kind of look at the different types of testing. The key elements could be what matrix are you using? Is it urine, hair, sweat, even though most of the testing we're doing in pain management clinics are with urine testing.

The second I think matrix is, the second thing to look at is what's the timing of the test? Is the test going to be used as a screening tool initially when you see a new patient and you may make clinical decisions on that first date? Or is the more confirmatory testing going to be used over time, or if you see a discrepancy in the test? So, there's different time points and how we're using these tests, whether you need an answer in the short-term, or you need to confirm something that is going to be found out maybe two or three days after the visit, but you can use that information to help guide your management. So those are the kind of main areas. Again, what type of testing you're doing. And then what's the timing of the testing.

Dr. Caudle:
And what are some of the short and long-term impacts of effective drug monitoring?

Dr. Stanos: 
So, the short and long-term impacts of effective drug monitoring can include a number of things. In the short term, doing urine monitoring, including immunoassay testing in the office can give you a quick result. It may not be as sensitive and specific but it may help you to make an early clinical decision say for a new patient or a patient that you've been following for many months. The long-term benefits could be from a timing standpoint over time, you may need to get a confirmation testing send out for gas or liquid chromatography where you can get more information on the metabolites and confirm or clear up any discrepancies that you may have found with the immunoassays that were originally done.

I think in the bigger picture, the long-term impact of doing urine monitoring in your clinic in your practice is really establishing a better therapeutic relationship with your patient. And most importantly, preventing harm.  Many times an abnormal urine screen in confirmatory testing, may be the first information you receive that the patient may be struggling with opioid use disorder, or they are using alcohol again, or they're smoking cannabis or taking other medications that you didn't know about or that they didn't even understand are being tested for in their urine. So I think most importantly the long-term benefits are to really help improve patient safety. And really using the results of any type of monitoring to make the right clinical decisions for your patients.

Dr. Caudle:
As we continue to monitor our patients, are there any particular drugs we should be on the lookout for or test for?

Dr. Stanos: 
Yes, as we're monitoring patients, I think it's important to first know when we're testing what are the metabolites of the drugs that we're prescribing? Because we're going to need to understand that when we're looking at results, especially with the confirmatory testing.

One important thing to remember about immunoassay testing, and those are the types of testing that we use with most point of care tests, is that they're enzyme-based or antibody-based tests. So, they do a really good job of identifying opioids that are related to the opium poppy like morphine and codeine. So unfortunately, they're not good to identify the synthetic or semi-synthetic opioids, which are primarily the medicines that we prescribe. So many times, the immunoassay may be negative.  So, it's really going to be important for providers to do the confirmation testing or have a good understanding of the limitations with the actual type of immunoassay testing that they're using in clinic.

The other thing we're seeing more frequently or more recently, is because of the increased use of illicit fentanyl and the use of illicit fentanyl in a lot of the street supply of illicitly manufactured opioids, which you may as a prescriber not be writing obviously, but patients may be getting their hands on. We are seeing in clinics, as well as in emergency departments, especially increasing fentanyl because there's so much fentanyl that is now being illicitly used within the whole supply in the community. So, many clinics and many emergency rooms now are also testing for fentanyl with patients. Many times, patients don't even know that they're using those substances, or those substances are included in that. I think also testing for alcohol.  We send out in our clinic confirmation testing for glucuronide. Many times, you may pick up from a patient who may be saying that they're not drinking or they've been abstaining from alcohol and there may be other issues with the patient's presenting that may not be the case. And so testing for alcohol, I think can be an additional test that you can use. But I do think, just with all the changes with the illicit use of fentanyl using in testing with confirmation testing for fentanyl may be something we do more often than we did say 5 and 10 years ago.

Dr. Caudle:
And before we close, let's look to the future. How do you think implementing more effective drug monitoring practices will impact the drug misuse landscape?

Dr. Stanos:
I definitely feel that implementing drug monitoring earlier in practice and doing this within not just primary care, but in specialty care clinics is hopefully going to help impact in a positive way decreasing the significant effect of the drug overdose epidemic in this country. Doing drug monitoring early on and even within a pain management practice at the specialist level can really help pick up on problems that a patient's developing whether it's a person that's developing opioid use disorder, or they're using their medications for different reasons that aren't really clinically appropriate can really help, I think, guide a patient's care in the right direction sooner. And really doing this later, when things have really gotten out of control. So really, the idea of monitoring is really going to help pick up on patients earlier that may be developing problems with medication use.

The second part I think is important, which is sometimes ignored, is the area around diversion. Many times, unfortunately the patients may not be truthful with us about, let's say their pain condition. And they may be diverting the medicines for to sell them or to obtain for money to buy other drugs. And without doing urine monitoring we're not really doing our job to try to limit prescription medications getting into the community for the wrong reasons.

So, I kind of look at it in two ways. There's the most important part is to prevent harm for our patients and to pick up early on any type of problem they may be struggling with, with regards to a substance use disorder. And second, really trying to limit and pick up on any type of diversion that may be occurring, even though it's pretty rare in clinical practice. But medications like that are only going to get into the community, and many times into the wrong hands, and also cause significant harm. So, both of those. Looking at the patient with chronic pain that may be struggling and picking up on an opioid use disorder or substance use problem.  And then also trying to limit diversion.

Dr. Caudle:
Well, with those forward-looking thoughts in mind, I'd like to thank my guest, Dr. Steven Stanos, for joining me to discuss the role of medication monitoring in reducing the heavy tolls of drug misuse. Dr. Stanos, it was great having you on the program.

Dr. Stanos:
Thanks for having me, Dr. Caudle. I enjoyed my time with you. And I really appreciate the invitation. 

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You’ve been listening to Clinician’s Roundtable, and this episode was sponsored by Quest Diagnostics. To access other episodes in this series, visit reachmd.com/cliniciansroundtable, where you can Be Part of the Knowledge. Thanks for listening!